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recurance

John Humphries

1 Sept 2021 · Coroner Jonathan Landau · South London

The coroner's concerns

  1. 1. pressure sores

    “I heard evidence that Mr [name redacted]' pressure sore probably started in A&E where he stayed for a long period before being moved to a ward. I was not informed of any skin integrity assessments or measures whilst he was in A&E.”
  2. 2. lack of external professional consultation

    “When Mr [name redacted] resisted being turned, no advice was sought from external professionals or the nursing home as to how to manage the situation. The nursing home in particular had effectively employed a range of strategies to deal with the situation and would have been able to provide guidance had the staff been contacted.”

Responses

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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

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